Tuesday, May 19, 2009

Where have all the medical students gone?

I write this blog from a briefing for medical students and internal medicine residents attending ACP's Leadership Day on Capitol Hill. They are learning what they can do, with their colleagues in internal medicine practice, to get Congress to support ACP's priorities:

Ensure that all Americans will have access to affordable health insurance coverage and access to a general internist or other primary care physician.

As I look around the room, I am encouraged that so many energetic and optimistic young people - more than 100 in all - took time out of their studies and residency programs to learn about health policy. No one can make a better case for health care reform than the next generation of physicians.

Yet, if asked a few years hence, "Where have all the medical students gone?" it won't be general internal medicine, family medicine, or pediatrics. That is, unless something big happens to make primary care more appealing.

Right now, about one out of three doctors in the U.S. are in primary care specialties, compared to the 50/50 mix found in other countries with higher performing health care systems. This would be bad enough, but unless next year's graduating class (and the ones that follow) are given a reason to look more favorably on primary care, fewer than one in five physicians will be in primary care. We know this because only 17% of U.S medical school graduates in 2008 expressed a desire to go into primary care, an all time low. We also know from studies that without more primary care physicians, the American people will experience higher cost of care and lower quality.

I don't write this to put a damper on the eagerness of the medical students in this room. The fact that so few of them are thinking about going into primary care isn't a statement about them, but a statement about us, as a nation. If we really believe that patients should have a personal physician who is trained in comprehensive and longitudinal care, then we would show this to our medical students. We would pay primary care doctors better, reduce the paperwork and hassles (see yesterday's blog) associated with primary care, pay off their debt, and expose them to the joys of primary care in their training.

Tomorrow, I will be writing about a major new piece of legislation to be unveiled by Rep. Allyson Schwartz (D-PA) that will offer a comprehensive plan to realign federal health policy to produce more primary care physicians.

If this bill were enacted into law, as ACP hopes it will, we may soon be able to report that medical students are going into general internal medicine, family medicine and pediatrics. And the country will be better off as a result.

Today's question: Do you think that medical students' lack of interest in primary care is something that can be remedied by the federal government?

3 comments
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Of course it can be remedied. The more pertinent question is, whether there is the will to do what is right rather than what is expedient. Whether the Specialty lobby and their allies will allow it to get done, and whether the public even has any idea of what they will be missing out on with current trends.The purveyors of the status quo have been so successful in framing the argument that the task of getting what is needed and right is very difficult, and will take time. The AMA and its support of the constitution of RUC in favor of specialty medicine and the resulting misallocation of RVUs is central to the pay disparity. The Insurers have piled onto the misery by worsening these exacerbations and then adding on their own layering of red tape and paperwork for good measure.All this in combination with the 24/7 nature of the traditional practice of medicine, has made the career very unattractive. The results are not surprising. Even at this final stage of the evisceration of generalist led primary care the AMA has not come to its senses, they tabled whether to support the advanced medical home for further study. They arguably have decided to let the ship go down in support of the RUC.I have long said that the General Internist is the best value in health care today, if the current system of insurance falls, I suspect we will not be a loser. I can't say that about every area of medicine. The AMA needs to understand that this is one fight PCPs cannot shirk, for their very existence as a specialty depends on it. We are truly facing an existential threat as a career.

Frankly, the government is one of the biggest factors for disincentivizing primary care. Its history of regulations and price fixing have left the cornerstone of high-quality medical care to nothing more than a 15 minute quick fix. The best way the government can adjust things is to reverse its obligatory burden on practicing physicians. To get started, the government should encourage patients to use physicians who are not burdened with insurance paperwork and regulations and patient-volume by providing patients with tax credits proportional to income level for using the services of concierge medical practices or medical homes. Essentially, the government needs to completely remove itself and insurance from the relationship between a primary care physician and the patient.

If the government lets primary care doctors be primary care doctors while backing that up with an income that is on par with other specialties, the number of medical students entering primary care will skyrocket.

Today's question: Do you think that medical students' lack of interest in primary care is something that can be remedied by the federal government?

The solution to medical students' lack of interest in primary care will be multi-polar, based on the complexity of the problem.

Many students are "interested", but consider a career in the "primary care" specialties financially untenable. Their debt burden from education is at a historic high and that $2000/month for 25 years loan payment looms pretty high as well. Structured debt repayment programs and enhanced income for physicians in these specialties as a result of action on the part of the federal government's lead are a good first step in the right direction.

Other things have to happen, too:1. generational concerns: young physicians are very interested in protected time: better lifestyles than their predecessors. They'll want some assurance that the jobs they'll take have favorable call schedules, office or hospital duties but not both (which was part of the long work hours piece, previously), some will want part-time positions, particularly women, and most will not want to endure the hard-ships of starting new practices or joining small existing ones, but will be content to take walk-in/turn-key positions with deep-pockets organizations like staff model hmo's and hospital systems that'll subsidize their incomes and take the hit on their start-up costs for the first couple of years. They'll want abundant support staff to make their days go smoother and decrease the number of calls they need to make at the end of the day, and decrease the endless stream of paperwork that otherwise would come their way, by doing it for them.

2. mentors: med students are going to need to work with and sense satisfaction, enjoyment and pride from their mentors who practice the "primary care" specialties. There isn't alot of this to go around right now, and I think it is going to take even the turnover of a generation of physicians before this changes. "Forced smiles" won't work, and there is an ocean of negative sentiment out there right now, the temperature of which will not change quickly.

3. other forces: the medical insurance companies and the pharmaceutical companies conspire to become rich at the expense of patients, physicians and employers. The federal government is going to need to exert price controls on pharmaceuticals, and to exert policy changes through laws that prohibit insurers from skimming so much administrative dollars from the health care premium, while erecting elaborate prior-authorization barriers to patient care that delay necessary care and tie up "primary care" physicians and their staff with expensive and time consuming unnecessary wasted effort. Sadly, I predict that the Gov't won't have the political stones to do this, and this system will have to fall flat on its face, then be resurrected by the government with a salvage single payer system.

Meanwhile, non-resolution of these other problems in our health system wil maintain high hassle factors and low physician pay from private payers that will dilute the effect of government led stimulation of the "primary care sector". ? Too little, too late?